198602134-6-20-2023-11-AS-RORN-CTVKCB-20230719074650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 06/19/2023
Date Signed: 06/20/2023 09:47:29 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2023 and conducted by Evaluator Lizeth Villegas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230615131524

FACILITY NAME:	GLEN PARK AT LONG BEACH		FACILITY NUMBER:	198602134
ADMINISTRATOR:	CAMILLE CRENSHAW		FACILITY TYPE:	740
ADDRESS:	1046 E 4TH ST		TELEPHONE:	(562) 432-7468
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	208	CENSUS: 76	DATE:	06/19/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Michael Mendoza		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failled to accept the resident back from the hospital.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/19/23 Licensing program analyst (LPA) Lizeth Villegas and licesnig program manager
(LPM) Janae Hammond conducted an intial compaint visit regarging the above allegation and met with Administrator Michael Mendoza as the purose of todays visit was explained.

The investigation consisted of the following: On 06/19/23 LPA/ LPM interviewed Adminstrator
Michael Mendoza and interviewed wintness #1. LPA/LPM obtained copies of the resident and staff rosters and copies of residents file (facesheet, physicians report, medication list, physicians orders, discharged summary from hospital).

The investigation revealed the following: On 06/19/23 LPA/LPM interviewed
Administrator Micheal Mendoza regading the above allegation, Administrator stated that on 06/14/23 resident #1 sustained a fall resulting in resident obtaining a bump on back of the head. Administrator reported resident #1 was transported to the hospital following the fall, Administrator reported that on

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 11-AS-20230615131524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
	VISIT DATE: 06/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Thursday around 3 am stating that resident was going to be discharged back to the facility. Administrator stated that the hospital was informed that additional info is needed prior to resident returning to facility. Administrator stated that the hospital failed to provide additional info on residents assessments for the head injury and possible UTI. Per Administrator, Administrator once again asked for additional info after
receiving another call from hospital stating that resident would be transported back to the facility at 11 am, resident arrived back to the facility on 06/15/23 around 11:15 am. Administrator denied informing the hospital that Administrator would not be accepting resident back to the facility.

On 6/19/23 LPA/LPM interview witness #1 regarding above allegation, witness #1 denied the allegation and stated that the facility did not deny residents return to the hospital as witness #1 and Administrator had constant communication regarding residents plan of care.

LPA and LPM were unable to interview resident #1 as resident #1 is currently at a rehabilitation facility. LPA/LPM reviewed resident #1 discharged paperwork from St. Mary's Medical Center.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted to Administrator Michael Mendoza and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2